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Awls eommereeml.gov Safety and Buildings Division County <br /> a 201 W.WashingtonAve.,P.O.Box 7162 Qfpvq e-' ' <br /> iseonsin Madison,WI 53707-7162 SanitaryP it Number(to be filled in by Co.) <br /> DOpertnarn of commerce <br /> Sanitary Permit Application StsteT am 'an Nurnber <br /> In xcordanca with a.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate govamnremal <br /> unit is squired Prior to obtaining a sanitary permit Note: Application foam for stat"wned pOWTS are project Addr as(if different than mailing address) <br /> submitted to the Department of Commerea Personal information you provide may be used for secondary <br /> purposcainaccordancewRln the Privacy Law,a.15. 1 m Stats. <br /> 1. ADDlication Wormation—Plea Print AOlnformation 30�8s���lol` aJaAwJan R . C� <br /> property Owner's Name Parcel# —y <br /> D.a, /�/e0sIle r �0 o3a drd do us 600 <br /> Property Owner's Mailing Address Property tion <br /> /03// /07r-* Sr Al 1t <br /> City,State Zip Code Amne Number GovL Lot A <br /> sf:/� C✓a{6•/ It')A/ YS Y., Section 6 <br /> •SS"U 844 ce� <br /> IL Type of Building(checkall that aPP1Y) Lot# T Y/ R IA- E <br /> .3 l or 2 Family Dwelling-Number ofBedrooma SubdivisionTanic <br /> r <br /> Block# <br /> ❑PublidCommereul-Describe Use <br /> 0 City of <br /> — <br /> 0 State Owned-Describe Uee CSM Number ❑.t Village of <br /> U <br /> Town of f nr' jf <br /> IIL <br /> Type of Permit: (Check only nate boz m Ibae A Complete line B it applicable) <br /> A. yi New System ❑Replacement System 0 Tieatmmt/Holdin Tank <br /> g Replacesmt only <br /> ❑Other Modi Ficatio,to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permrt Revision ❑Change of Plesber 0 Pemnrt Tranfer to New List Previoae F m it Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS tem/Caa ent/Devlce: Check all dust apply) <br /> '6Nm-PMaur¢ed InGroumd 0 p}eaaurixed ln-Cnuuod 0 At-Conde 0 Mound>24 in.of sortable soil 0 Monad in.of suitable Boil <br /> 0 Holding Tank 0 Other Dispersal Cespmeat(explain) ❑Pretreatment Device(explain) <br /> V. ersalfrtatment Area Information: <br /> Design Flow(gpd)JD;wignApplicationRate(gpde1 Disperul Area Required(so Dispersal Anes Proposed(at) Systes Elevation <br /> OroGVL Tank Wo Capacity in Total #of MawBcturuGallons Gallon Unite Septic or Holding Tan /000 <br /> /dao <br /> Doa>R ch.mbar 6O0 600 <br /> VII.Responsibility Statement-i,the undenigaed,assume responsibility for installation of the POWTS shown on the an hed planx <br /> Plumber's Name(Print) Plumber's Signature MP/bBaRS Number Bnineea Anon Number <br /> Humber's Address(Street,City,stale,Zip Code) <br /> 7760 ar 3rS tve/asfe, ws s5` VV 3 <br /> L Conn /De ahnent se Od <br /> roved 0 Disapprovedt Fee Date haired Iuuin gem S <br /> ❑Owner Giem Reum for Iknul <br /> asa.c� N ao cr/ <br /> DL Conditions of Appreval/Reasons far Disapproval <br /> Amahm"aspkle plana for toe ayslea send auhaa m/he Cmmy ody an paper on,kaa than a In a tl I.b. ske <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />